Effect of two different techniques of arteriovenous fistula puncture on wound infection in haemodialysis patients.

Safe and effective arteriovenous fistula (AVF) puncture is very important to reduce the wound complications of haemodialysis (HD). For AVF puncture in dialysis patients, there is a lack of clarity and consistency regarding the relative advantage of buttonhole (BH) over rope-ladder (RL) cannulae in terms of wound complications. The study was published in several scientific databases including Cochrane Library, PubMed and Embase by October 2023. Data from all controlled trials looking at the effect of BH and RL on wound complications in haemodialysis patients were included. The articles were written in English, and they were about adult who had AVF while on dialysis. Studies with or without BH or RL treatment were excluded from the analysis. The data was analysed with RevMan5.3 software. Out of 215 trials, 9 were chosen for the final analysis. The study publication dates were between 2000 and 2023. Of these, 17 326 patients received AVF therapy. Among them, there were 3070 BH and 14 256 RL. In 9 studies, RL had a lower risk of postoperative wound infection compared to BH (OR, 3.38; 95% CI, 3.06, 3.73 p < 0.0001); In all 3 studies, there were no statistically significant differences in the risk of post operative bleeding in RL versus BH(OR, 0.76; 95% CI, 0.25, 2.33 p = 0.63). Our studies have demonstrated that RL trocars are superior to BH trocars in the prevention of wound infection.

Cannulation Technique of Vascular Access in Hemodialysis and the Impact on the Arteriovenous Fistula Survival: Systematic Review and Meta-Analysis.

Adequate cannulation technique (CT) methods and successful puncture are essential for hemodialysis (HD) and arteriovenous fistula (AVF) maintenance. This systematic review and meta-analysis was designed to identify which CT allows better AVF primary patency and lower rates of complications in HD patients. The search was carried out on the CINAHL, MEDLINE, Cochrane Library, and Joanna Briggs Institute Library databases to identify all randomized controlled trials (RCTs) and observational studies comparing clinical outcomes of buttonhole (BH) versus rope ladder cannulation (RL) from 2010 to 2022. The Risk-of-Bias (Rob 2) tool was used for RCTs and the ROBINS-I was used for non-randomized studies. RevMan 5.4 was used for the meta-analysis. A total of five RCTs, one quasi-randomized controlled trial, and six observational studies were included. When compared with RL cannulation, BH cannulation significantly increased bacteremia (RR, 2.76, 95% CI (1.14, 6.67), p = 0.02) but showed no differences in AVF primary patency (HR, 1.06, 95% CI (0.45, 4.21), p = 0.90). There was no thrombosis reduction (RR, 0.51, 95% CI (0.23, 1.14), p = 0.10) or intervention number reduction (RR, 0.93, 95% CI (0.49, 1.80), p = 0.84) with BH. Outcomes like pain, hematoma, and aneurism could not be merged due to a lack of data, reported as medians, as well as due to different definitions. The quality in general was poor and the heterogeneity among the studies prevented us from merging the outcomes.

How to choose the appropriate cannulation technique for vascular access in hemodialysis patients.

The cannulation technique is important for the survival of the arteriovenous access. Choosing the appropriate technique is a complex decision. Such choice must be customized to patients, considering their characteristics, the type of arteriovenous access and the experience of the hemodialysis team. We describe seven items that can help nurses to identify the appropriate cannulation technique: type of arteriovenous access; drainage vein; hygienic self-care profile; experience of the nursing staff in the cannulation technique and nurse-to-patient ratio; hemodialysis treatment method; patient's condition; and patient's decision. Such items can help nurses in decision-making on the "ideal" cannulation technique for each patient.

How to needle: A mixed methods study on choice of cannulation technique for arteriovenous fistula.

AIMS AND OBJECTIVES: The aim of this study was to describe the basis for choosing a cannulation technique for arteriovenous fistula. BACKGROUND: Four cannulation techniques are relevant to cannulating an arteriovenous fistula: rope ladder, area puncture and buttonhole using blunt or sharp needles. The chosen technique may affect both the patency and number of complications. DESIGN: The study used a convergent mixed methods design and inductive approach. METHODS: A questionnaire and an inquiry of local guidelines were sent to nurses in all dialysis units in Sweden. Questionnaires were answered by nurses from 37 units, and 29 units included their local guidelines. The questionnaires were analysed using descriptive statistics and qualitative content analysis, and the guidelines were analysed using qualitative content analysis. The different analyses were combined in a final result. The study is based on GRAMMS guidelines. RESULTS: Local guidelines, patients' and nurses' own judgement, and consultation with colleagues were found to greatly influence the choice of cannulation technique. Buttonhole was the most preferred cannulation technique in the participating units and was favoured by nurses when choosing a cannulation technique. The process of choosing a cannulation technique was found to be influenced by the dedication to good cannulation technique and healthy arteriovenous fistulas, whether the technique is perceived as being easy to use and is expected to prevent complications and based on the experienced-based knowledge of each dialysis unit. CONCLUSIONS: Choosing a cannulation technique is a process based on the nurse, local guidelines and the patient. Most dialysis nurses and units in Sweden consider buttonhole to be a good cannulation technique and use it as their standard technique. RELEVANCE TO CLINICAL PRACTICE: The results provide insight into why cannulation techniques are chosen differently in different units. The results also show the importance of evidence in making decisions on cannulation technique.

Inferior vena cava thrombosis-rope ladder sign.

Congenital heart disease comprises one of the largest groups of congenital defects, affecting approximately 1% of births. Advances in pre- and postoperative critical care treatment as well as surgery and interventional procedures have improved survival rates, but treatment and long-term care of children with complex congenital heart disease remains challenging, and is associated with a number of complications.Here, we report on a 17-month-old infant with congenital univentricular heart disease who devloped post-operatively inferior vena cava (IVC) thrombosis. IVC thrombosis was confirmed by a bedside contrast media study (X-ray) demonstrating collateral paravertebral circulation along the paravertebral sinuses bilaterally into the azygos and hemiazygos vein ("rope ladder sign"), with no contrast media detected in the IVC. The infant was subsequently started on aspirin and clopidogrel.

A randomised control trial protocol of MuST for vascular access cannulation in hemodialysis patients (MuST Study): contributions for a safe nursing intervention.

BACKGROUND: The vascular access preservation and the maintenance of a complication-free fistula remains an Achilles' heel of hemodialysis in chronic kidney patients due to its substantial contribution to the morbidity and mortality. Systematic studies in the area of examining cannulation practices, achieving complication-free cannulation, and strategies to improve fistula survival are needed. For this reason, we consider it essential to create and investigate new methodologies for approaching fistula in patients on regular HD. The Multiple Single Cannulation Technique (MuST) is based on the association between the rope-ladder (RL) using the arteriovenous vessel through progressive rotation, and the buttonhole (BH) since there are three specific cannulation sites for each cannulation day during the week. The MuST is simple to implement and seems to be a very promising technique in terms of patient safety. Previous studies already showed an arteriovenous fistula survival similar to RL but significantly higher than BH. METHODS: This MuST study is a multicenter, prospective, non-blind, parallel-group, randomized controlled trial with the intervention group submitted to MuST and a control group undergoing the rope-ladder, up to 100 subjects for each group. Patients will be randomized 1:1 to one of two cannulation technique (CT), and the follow-up period of this study will be 12 months. Primary outcome is to evaluate the arteriovenous fistula survival rate at 12 months determined by the percentage of fistulas in use from the beginning of the study to the date of the first clinical intervention by angioplasty or vascular surgery, to maintain or restore patency (unassisted patency). Secondary outcome is to evaluate arteriovenous fistula survival rate at 12 month determined by the percentage of fistulas in use from the study start to the date of access abandonment due to dysfunction, patient abandonment, or death, treatment change modality or study end. We will also evaluate the assisted primary patency and include the following secondary outcomes associated with the cannulation technique: Infection, Hematoma, Aneurysm development, and pain. DISCUSSION: The study will investigate whether fistula survival can be improved when using cannulation by MuST compared to the RL. MuST study will provide important information on fistula survival when cannulated by MuST but also information related to its use in fistulas previously cannulated by other CTs. TRIAL REGISTRATION: ClinicalTrials.gov identifier NCT05081648 registered on 18 October 2021.

Multiple single cannulation technique of arteriovenous fistula: A randomized controlled trial.

INTRODUCTION: Despite the impact needling has had on vascular access survival and patient outcome, there is no universal or standardized method proposed for proper cannulation. Rigorous studies are needed, examining cannulation practices, and challenges to achieving complication-free cannulation. METHODS: This randomized, open-label trial was conducted at 18 dialysis units owned by a large private dialysis provider operating in Portugal. Eligible patients were adults on chronic hemodialysis, with a new arteriovenous fistula (AVF); cannulated for at least 4 weeks complication-free. Patients were randomly assigned in a 1:1 ratio to one of three cannulation techniques (CT): Multiple Single cannulation Technique (MuST), rope-ladder (RLC), and buttonhole (BHC). The primary endpoint was AVF primary patency at 1 year. FINDINGS: One hundred seventy-two patients were enrolled between March 2014 and March 2017. Fifty-nine patients were allocated to MuST, 56 to RLC, and 57 to BHC. MuST and RLC were associated with a better AVF primary patency than BHC. Primary patency at 12 months was 76.3% in MuST, 59.6% in BHC, and 76.8% in RLC group. Mean AVF survival times were 10.5 months (95% CI = 9.6, 11.3) in the MuST group, 10.4 months (95% CI = 9.5, 11.2) in RLC, and 9.5 months (95% CI = 8.6, 10.4) in BHC. BHC was a significant risk predictor for AVF survival with 2.13 times more events than the other two CT (HR 2.13; 95% CI = 1.07, 4.21; p = 0.03). DISCUSSION: MuST was easy to implement without a diagram and there is no need to use blunt needles. This study showed MuST was efficacious and safe in maintaining the longevity of AVF in dialysis patients.

Cannulation Technique of Vascular Access in Haemodialysis and the Impact on the Arteriovenous Fistula Survival: Protocol of Systematic Review.

BACKGROUND: Based on a literature review of various studies, comparisons between BH and RL are inconclusive regarding some outcomes. However, in the last 5 years, some studies have been published that may contribute to clarifying which cannulation technique (CT) allows better fistula survival. AIM: To review which cannulation technique allows better primary patency of the arteriovenous fistula in haemodialysis patients. METHODS: We will include all randomised controlled trials and observational studies that include comparisons among CTs and thus define the benefits and risks of each CT. A PRISMA-compliant systematic review and meta-analysis will be performed in accordance with the quality and homogeneity of studies. A comprehensive search strategy will be applied to the CINAHL, MEDLINE and Embase electronic databases from January 2000 to September 2021. The primary outcome is the arteriovenous fistula primary patency. To assess the risk of bias in randomised controlled trials or quasi-experimental studies, we will use the tool Revised Cochrane Risk-of-Bias Tool for Randomized Trials (RoB 2). For nonrandomised studies, the Risk of Bias In Non-Randomized Studies of Interventions (ROBINS-I) will be used. DISCUSSION: The evidence generated from this systematic review of current evidence could inform the design and implementation of continuous quality improvement programs in cannulation techniques in haemodialysis patients, as well as contributing to improving the curricula within haemodialysis courses. This protocol was registered with the National Institute for Health Research PROSPERO database prior to commencement (registration number CRD42021237050).

Cannulation technique and complications in arteriovenous fistulas: a Swedish Renal Registry-based cohort study.

BACKGROUND: The four cannulation techniques, rope ladder (RL), area puncture (AP), buttonhole with blunt needles (BHb), and buttonhole with sharp needles (BHs), affects the arteriovenous fistula (AVF) in different ways. The aim of this study was to describe the relationship between the different cannulation techniques and the occurrence of AVF complications. METHODS: The study was performed as a national registry-based cohort study using data from the Swedish Renal Registry (SRR). Data were collected from January 2014 to October 2019. Seventy of Sweden's dialysis units participate in the registry. We analyzed a total of 1328 AVFs in this study. The risk of complications was compared between the four different cannulation techniques. The risk of AVF complications was measured by the incidence and incidence rate ratio (IRR). We compared the IRRs of complications between different cannulation techniques. RESULTS: BHs is the most common cannulation technique in Sweden. It has been used in 55% of the AVFs at some point during their functional patency. BHb (29%), RL (13%), and AP (3%) has been used less. BHb had the lowest risk of complications compared to the other techniques, and a significantly lower risk of stenosis, infiltration, cannulation difficulties, compared to RL and BHs. Cannulation difficulties were significantly more common using AP compared to BHs, and BHb. Infections were not significantly increased using the buttonhole technique. CONCLUSIONS: BHb had the lowest risk of complications. Infections were not significantly increased using the buttonhole technique. Dialysis units with a low infection rate may continue to use the buttonhole technique, as the risk of complications is lower.

A comparison of the buttonhole and rope-ladder AVF cannulation techniques and infection rates within the SCOPE collaborative.

BACKGROUND: Studies regarding hemodialysis (HD) arteriovenous fistula (AVF) cannulation in adults indicate a higher risk of infection with the buttonhole (BH) technique compared to the rope-ladder (RL) technique. Pediatric data on this issue is sparse. METHODS: We compared infection rates within the Standardizing Care to Improve Outcomes in Pediatric End stage kidney disease (SCOPE) centers performing BH cannulation versus RL cannulation of AVF. Generalized linear mixed modeling was used to assess differences in access-related blood stream infection (BSI) and access site infection (ASI) rates between the centers. RESULTS: Data was available from 211 AVF enrollments among 210 children. There were 61 AVF enrollments at 6 BH centers and 150 enrollments at 13 RL centers. Demographics were similar between the two groups. There were 12 total infections in 3383 patient months. BH centers had 3 infections (0 BSI, 3 ASI) and RL centers had 9 infections (5 BSI, 3 ASI). Mean [95% confidence interval] infection rates per 1000 patient months were not different between BH and RL centers (BH: 3.1 [0.6,15.6], RL: 3.2 [1.3,9.4], p = 0.947). A survey was also completed by the BH centers to describe their BH practices. The BH procedure at the majority of sites was characterized by a small patient/nurse ratio and strict antiseptic protocols. CONCLUSIONS: This data provides evidence of a low BSI rate associated with BH cannulation in pediatric HD patients. Further studies are needed to better delineate the differences in the pediatric and adult experience with the BH cannulation technique.

Safe Needling of Arteriovenous Fistulae in Patients on Hemodialysis: Literature Review and a New Approach.

Although buttonhole cannulation has some benefits compared to rope-ladder cannulation, the increase of infection rates represents a major obstacle to patient safety, and its use is questionable in routine clinic practice. On the other hand, rope-ladder cannulation is difficult to implement even with a prescribed protocol, leading the cannulator in daily practice to a possible use of the area technique. This article provides a reflection on the impact of cannulation technique on the safety of patients on regular hemodialysis treatment and describes a new approach for arteriovenous fistula cannulation, the Multiple Single Cannulation Technique (MuST). The MuST has not been described before, but it has been used with promising results. Further studies are needed to confirm the benefits of this cannulation technique.

Risk of Vascular Access Infection Associated With Buttonhole Cannulation of Fistulas: Data From the National Healthcare Safety Network.

RATIONALE & OBJECTIVE: Compared with conventional (rope-ladder cannulation [RLC]) methods, use of buttonhole cannulation (BHC) to access arteriovenous fistulas (AVFs) may be associated with increased risk for bloodstream infection and other vascular access-related infection. We used national surveillance data to evaluate the infection burden and risk among in-center hemodialysis patients with AVFs using BHC. STUDY DESIGN: Descriptive analysis of infections and related events and retrospective observational cohort study using National Healthcare Safety Network (NHSN) surveillance data. SETTING & PARTICIPANTS: US patients receiving hemodialysis treated in outpatient dialysis centers. PREDICTORS: AVF cannulation methods, dialysis facility characteristics, and infection control practices. OUTCOMES: Access-related bloodstream infection; local access-site infection; intravenous (IV) antimicrobial start. ANALYTIC APPROACH: Description of frequency and rate of infections; adjusted relative risk (aRR) for infection with BHC versus RLC estimated using Poisson regression. RESULTS: During 2013 to 2014, there were 2,466 access-related bloodstream infections, 3,169 local access-site infections, and 13,726 IV antimicrobial starts among patients accessed using BHC. Staphylococcus aureus was the most common pathogen, present in half (52%) of the BHC access-related bloodstream infections. Hospitalization was frequent among BHC access-related bloodstream infections (37%). In 2014, 9% (n=271,980) of all AVF patient-months reported to NHSN were associated with BHC. After adjusting for facility characteristics and practices, BHC was associated with significantly higher risk for access-related bloodstream infection (aRR, 2.6; 95% CI, 2.4-2.8) and local access-site infection (aRR, 1.5; 95% CI, 1.4-1.6) than RLC, but was not associated with increased risk for IV antimicrobial start. LIMITATIONS: Data for facility practices were self-reported and not patient specific. CONCLUSIONS: BHC was associated with higher risk for vascular access-related infection than RLC among in-center hemodialysis patients. Decisions regarding the use of BHC in dialysis centers should take into account the higher risk for infection. Studies are needed to evaluate infection control measures that may reduce infections related to BHC.

Buttonhole Cannulation of Arteriovenous Fistulas in the United States.

The cannulation technique of a hemodialysis vascular access has remained controversial with differing viewpoints. The quality of dialysis, overall patient safety, and individual dialysis experience often dictate the type of cannulation technique used in clinical practice. The three commonly used techniques to access a hemodialysis vascular access are the rope ladder, area, and buttonhole. Although the buttonhole technique has been around since the mid-1970s, the dialysis community remains divided on its suitability for routine use to provide maintenance hemodialysis therapy. The proponents of this technique value the ease of cannulation with less pain and discomfort whereas the opponents highlight the increased risk of infection. The actual clinical evidence from the United States is limited and remains inconclusive. The current review provides an overview of the available experience from the United States, highlighting the correct technique of creating a buttonhole, summarizing the current evidence, and recommending a need for larger randomized controlled studies in both in-center and home hemodialysis populations.

Cannulation Technique and Arteriovenous Fistula Survival in Older Adult Patients on Hemodialysis.

Cannulation technique has the potential to impact arteriovenous fistula (AVF) function. The aim of this research was to determine the impact of cannulation technique on the length of the functioning AVFs in older adult patients on hemodialysis. The study included 110 participants with fistula thrombosis who had used area technique or rope ladder technique. Biochemical parameters, gender, demographic, and clinical variables were determined. Patients who used the area cannulation technique differed significantly from patients using the rope ladder technique with regard to duration of hemodialysis (p < 0.001), outcome of the AVF revision (p = 0.045), and positioning of the anastomosis (p = 0.013). The group that used the area cannulation technique had a longer duration of hemodialysis, proximal anastomoses, and more successful revisions of AVFs.

The care and keeping of vascular access for home hemodialysis patients.

Creating and maintaining a healthy vascular access is a critical factor in successful home hemodialysis (HD). This article aims to serve as a "how-to manual" regarding vascular access issues for both patients and health-care providers in a home HD program. This document outlines cannulation options for patients with arteriovenous access and describes troubleshooting techniques for potential complications; strategies are suggested to help patients overcome fear of cannulation and address problems associated with difficult cannulation. Technical aspects of central venous catheter care, as well as a guide to troubleshooting catheter complications, are covered in detail. Monitoring for access-related complications of stenosis, infection, and thrombosis is a key part of every home HD program. Key performance and quality indicators are important mechanisms to ensure patient safety in home HD and should be used during routine clinic visits.

Buttonhole versus rope-ladder cannulation of arteriovenous fistulas for hemodialysis: a systematic review.

BACKGROUND: The buttonhole technique is an alternative method of cannulating the arteriovenous fistula (AVF) in hemodialysis (HD), frequently used for home HD patients. However, the balance of risks and benefits of the buttonhole compared with the rope-ladder technique is uncertain. STUDY DESIGN: A systematic review of randomized trials and observational studies (case reports, case series, studies without a control group, non-English studies, and abstracts were excluded). SETTING & POPULATION: HD patients (both in-center conventional HD and home HD) using an AVF for vascular access. SELECTION CRITERIA FOR STUDIES: We searched MEDLINE, EMBASE, EBM Reviews, and CINAHL from the earliest date in the databases to March 2014 for studies comparing clinical outcomes of the buttonhole versus rope-ladder technique. INTERVENTION: Buttonhole versus rope-ladder cannulation technique. OUTCOMES: The primary outcomes of interest were patient-reported cannulation pain and rates of AVF-related local and systemic infections. Secondary outcomes included access survival, intervention, hospitalization, and mortality, as well as hematoma and aneurysm formation, time to hemostasis, and all-cause hospitalization and mortality. RESULTS: Of 1,044 identified citations, 23 studies were selected for inclusion. There was equivocal evidence with respect to cannulation pain: pooled observational studies yielded a statistical reduction in pain with buttonhole cannulation (standardized mean difference, -0.76 [95%CI, -1.38 to -0.15] standard deviations), but no difference in cannulation pain was found among randomized controlled trials (standardized mean difference, 0.34 [95%CI, -0.76 to 1.43] standard deviations). Buttonhole, as compared to rope-ladder, technique appeared to be associated with increased risk of local and systemic infections. LIMITATIONS: Overall poor quality and substantial heterogeneity among studies precluded pooling of most outcomes. CONCLUSIONS: Evidence does not support the preferential use of buttonhole over rope-ladder cannulation in either facility-based conventional HD or home HD. This does not preclude buttonhole cannulation as being appropriate for some patients with difficult-to-access AVFs.